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Original research
General anesthesia during endovascular therapy for acute ischemic stroke: benefits beyond better reperfusion?
  1. Claus Z Simonsen1,2,
  2. Mads Rasmussen3,
  3. Silvia Schönenberger4,
  4. Pia Löwhagen Hendén5,
  5. Julian Bösel4,6,
  6. Jan Brink Valentin7
  1. 1 Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
  2. 2 Clinical Medicine, Aarhus University, Aarhus, Denmark
  3. 3 Department of Anesthesia, Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark
  4. 4 Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
  5. 5 Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
  6. 6 Department of Neurology, General Hospital Kassel, Kassel, Germany
  7. 7 Danish Centre for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
  1. Correspondence to Dr Claus Z Simonsen, Department of Neurology, Aarhus University Hospital Palle-Juul Jensen Boulevard 998200, Aarhus, Denmark; clasim{at}


Background Endovascular therapy (EVT) is standard of care for stroke caused by large vessel occlusion. Whether EVT should be performed under general anesthesia (GA) or conscious sedation (CS) is controversial. While a meta-analysis of randomized trials showed better outcome for EVT under GA, observational studies suggested the opposite. A proposed advantage of GA is better reperfusion achieved via more successful handling of the immobile patient. The aim of this study was to investigate if the good outcome seen in patients treated under GA was mediated by better reperfusion.

Methods The meta-analysis included 368 individual patients from three randomized controlled trials, of whom 185 patients were randomized to CS. A mediator analysis was performed to examine if the better outcome in the GA arm was driven by higher reperfusion rate.

Results The total effect showed a risk difference (RD) of 0.15 (95% CI 0.04 to 0.25), associating GA with a beneficial outcome. The direct effect of GA constituted a large portion, with an RD of 0.12 (95% CI 0.01 to 0.22), while only a small portion was mediated through the degree of reperfusion, with an RD of 0.03 (95% CI 0.02 to 0.04).

Conclusion The better outcome after EVT in the GA arm was mainly a direct effect—that is, an effect that was not explained by better reperfusion. We also found a better outcome in the GA arm when reperfusion was not achieved. Whether this is an effect of the stable condition and blood pressure under GA or a neuroprotective effect will need to be investigated in future research.

  • stroke
  • angiography
  • intervention
  • thrombectomy

Data availability statement

Data are available upon reasonable request. Data are available upon resonable request.

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Data availability statement

Data are available upon reasonable request. Data are available upon resonable request.

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  • Contributors CZS is the guarantor of the study. CZS: conceived idea and drafted the manuscript. SS, PLH, and CZS: inclusion of patients. MR, SS, PLH, and JB: edited the manuscript. JBV: statistical analysis.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

  • Competing interests MR and CZS are supported by research grants from Health Research Foundation of Central Denmark Region. CZS is also supported by a research grant from the Novo Nordisk Foundation. JB reports speaker honoraria and travel support from Medtronic and Pfizer and participation in a PCORI award for the SETPOINT2 trial, all unrelated to the study.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.